AFCA Upholds Insurer’s Decision in Breast Cancer Claim Case

2

The information on this website is general in nature and does not take into account your objectives, financial situation, or needs. Consider seeking personal advice from a licensed adviser before acting on any information.

The woman was diagnosed with cancer in her right breast on October 5 of last year, followed by the discovery of cancer in her left breast eight days later. She filed claims under her critical illness policy that she had obtained on July 17.

However, TAL Life, her insurance provider, rejected the claims based on the policy's three-month qualifying period for cancer coverage.

In its ruling, AFCA noted that the policy had provisions to potentially waive the qualifying period if the policyholder could prove they were insured either under a previous TAL policy or by another insurer for the same events, right before their new coverage commenced.

The claimant contended that she had cancer coverage through an insurance policy provided by her husband's employer. She presented a letter from the employer affirming that she was covered under a "life, accident, critical illness, and medical insurance" scheme from August 2020 until June last year. Additionally, she showed documentation indicating her husband’s policy did include critical illness coverage for spouses, encompassing cancer.

While AFCA accepted the availability of this cancer coverage, it was not convinced that she held such coverage "immediately before the current policy began." It also noted she had failed to disclose her previous insurance when applying for the new policy with TAL Life.

"There is no information before me about the extent of the critical illness cover the complainant had, if any, through her husband's employer’s insurance arrangements," AFCA’s ombudsman stated.

"Furthermore, it appears that any cover she might have had ceased about a month before the new policy started. I am not convinced there was 'continuity of cover' as suggested by the complainant."

The ombudsman expressed AFCA’s sympathy towards the claimant, especially given that the diagnoses occurred "very close to the end of the qualifying period." Nonetheless, he emphasized that there was no valid reason for the qualifying period to be dismissed.

"The qualifying period is reasonably short and its existence is not unjust. These terms are part of all insurance policies and they draw necessary boundaries. The enforcement of these terms is not inherently unfair," the ombudsman elaborated.

For a more detailed account of the ruling, refer to the original report by AFCA.

Published:Wednesday, 4th Sep 2024
Source: Paige Estritori

Please Note: If this information affects you, seek advice from a licensed professional.

Share this news item:

Insurance News

Clear

Global Insurtech Investments Halve as AI Adoption Rises

01 Jan 2026: Paige Estritori

The global insurtech sector experienced a significant downturn in funding during the fourth quarter of 2024, with total investments plummeting by 50% to US$688.24 million compared to the previous quarter. This decline marks the lowest annual funding level since 2018, with the total for 2024 reaching US$4.25 billion, a 6% decrease from the prior year. - read more

Australia's Insurance Market Set to Surpass $144 Billion by 2029

01 Jan 2026: Paige Estritori

The Australian general insurance industry is on a trajectory of significant growth, with direct written premiums (DWP) projected to exceed $144 billion by 2029. This forecast, provided by data and analytics firm GlobalData, indicates a substantial increase from the $94.7 billion recorded in 2024, reflecting a compound annual growth rate (CAGR) of approximately 8.8% over the five-year period. - read more

Australian Insurers Report $1.11 Billion Profit Amid Lower Catastrophe Claims

01 Jan 2026: Paige Estritori

The Australian general insurance industry has reported a net profit after tax of $1.11 billion for the March quarter, marking a significant financial upswing attributed primarily to a reduction in catastrophe-related losses. This performance underscores the industry's resilience and its ability to adapt to fluctuating risk environments. - read more

Australian Insurers Falling Behind in Risk Preparedness

24 Dec 2025: Paige Estritori

Recent findings from the PwC Insurance Banana Skins Survey reveal that Australian insurers are lagging behind their global counterparts in risk preparedness. The survey, which gathered insights from 698 insurance executives across 42 territories, indicates that Australian insurers scored 6.6% lower on the Preparedness Index compared to the global average. - read more

Rising Home Insurance Premiums in Australia

24 Dec 2025: Paige Estritori

Australian homeowners are facing significant increases in home insurance premiums, with average rates rising by 16% over the past year. This surge is largely attributed to the escalating frequency and severity of extreme weather events, which have led to higher claims and increased rebuilding costs. - read more

Click for more Insurance News